Brief Report

Non-expert clinicians’ detection of autistictraits among attenders of a youth mental

health serviceeip_288 83..86

Richard Fraser,1 Sue Cotton,2 Ellen Gentle,2 Beth Angus,2 Kelly Allott2 and Andrew Thompson2

1Sussex Early Intervention in PsychosisService, Horsham, UK; and 2Orygen YouthHealth and Orygen Youth Health ResearchCentre, Centre for Youth Mental Health,The University of Melbourne, Melbourne,Victoria, Australia

Corresponding author: Dr Richard Fraser,Sussex Early Intervention in PsychosisService, New Park House, North Street,Horsham RH12 1RJ, UK. Emailrick.fraser@sussexpartnership.nhs.uk

Received 12 January 2011; accepted 10July 2011

Abstract

Aims: The aims of this study were todetermine the point prevalence ofautism spectrum disorders and toestimate the prevalence of autistictraits in a youth mental healthservice.

Methods: Following three educationalsessions on autism spectrum disor-ders, treating clinicians were inter-viewed to determine whether theclients on their caseloads had (i) aconfirmed prior diagnosis of autismspectrum disorder; (ii) were felt toexhibit autistic traits; or (iii) were notfelt to exhibit autistic traits.

Results: Information on autism spec-trum disorder status was obtained for476 patients. Of the included patients,3.4% (n = 16) had a confirmed diag-nosis of autism spectrum disorderand 7.8% (n = 37) were reported bytreating clinicians to exhibit autistictraits.

Conclusions: The rate of autism spec-trum disorder was higher in thispopulation than that in communitysamples with twice as many againbeing identified as having autistictraits by their treating clinicians. Thishas implications for correct diagnosisand appropriate management inthese settings.

Key words: adolescent, autism spectrum disorders, co-morbidity,mental health, prevalence.

INTRODUCTION

Autism spectrum disorders (ASDs), classified the aspervasive developmental disorders (PDDs) in Inter-national Classification of Diseases, 10th Revision(ICD-10) and Diagnostic and Statistical Manual ofMental Disorders, Fourth Edition (DSM-IV), arecomplex developmental disorders that interferewith normal communication, social interaction orbehaviour. ASDs include autistic disorder, Aspergerdisorder and PDD not otherwise specified (NOS).Prevalence estimates vary, but ASDs may affect asmany as 1 per 100 children in general communitysamples.1,2 The prevalence of ASDs appears to haveincreased over recent years, the most likely explana-tion being a broadening of case definition and animprovement in recognition of these conditions.3

ASDs are associated with higher rates ofco-morbid mental illness.4,5 Such co-morbidity has

the potential to significantly worsen an individual’sfunctioning, quality of life and negatively affecttreatment outcomes.

There are two major diagnostic and treatmentissues pertaining to ASD and mental illness: (i)individuals with ASDs may present to serviceswith mental health difficulties, but the develop-mental disorder has not been previously recog-nized; and (ii) the overlap of symptoms ofASD and other psychiatric illness makes diagnosisproblematic and misdiagnosis common (seeFig. 1).6,7

Even though co-morbid mental illness is commonin ASD, at present, very little is known about theprevalence of ASDs in either adult or youth mentalhealth services.8,9 There have been no such reportsto date in youth mental health services (for peopleaged 12–25 years), an area of specific service growthin psychiatry.

Early Intervention in Psychiatry 2012; 6: 83–86 doi:10.1111/j.1751-7893.2011.00288.x

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The aim of this study was to describe the preva-lence of confirmed ASD and suspected ASD traits ina specialized youth mental health service, OrygenYouth Health (OYH).

METHODS

Design

In November 2007, a cross-sectional audit of thepoint prevalence of ASDs in OYH was conductedover a 4-week period. All clients registered with theservice at that time were included. There were noexclusions. Local ethics approval was obtained forthis project.

Treating clinicians were interviewed by threeresearchers (RF, AT, EG) over a 2-week period. Theywere presented with a prompt card detailing theDSM-IV PDD classification (autistic disorder,Asperger disorder and PPD NOS, but not includingRett’s disorder and childhood disintegrative disor-der). They were then required to classify each of theclients on their caseload into one of the followingthree categories based on their knowledge of theclient: (i) ASD diagnosis confirmed by a paediatri-cian, psychiatrist or clinical psychologist; (ii) sus-pected ASD traits; and (iii) ASD not suspected. Basicdemographic information (gender, age and clinic inwhich they were treated) was also available on allclients.

In addition to the written prompt, treating clini-cians had received three separate, local professionaldevelopment sessions on the diagnosis, treatmentand co-morbidity of mental illness and ASD in the2 months prior to the audit. This was provided by

the lead author (RF). The core elements of this train-ing were gaining an understanding of the ASDs asdevelopmental disorders, recognition of autistictraits, differentiation of autistic traits from otherpsychiatric presentations and the kinds of psy-chiatric co-morbidities expected to occur withthese conditions.

Setting

OYH is a public mental health service providing psy-chiatric care for young people between the ages of15 and 25 who live in the northwestern region ofMelbourne, Australia. OYH has a catchment areawith a population of about one million people fromdiverse sociocultural backgrounds. The service hasbetween 500 and 600 registered clients at any time.There are several specialist clinics within OYH,including the Early Psychosis Prevention and Inter-vention Centre – an early psychosis service, Per-sonal Assessment and Crisis Evaluation (‘ultra-highrisk’ for developing psychosis clinic) and Youth-scope (Youth Mood Clinic and HYPE clinic foremerging borderline personality disorder). The cli-nicians in the service are a mixture of psychiatrists,psychologists, nurses, social workers and occupa-tional therapists. For more information on theOrygen service, see http://www.oyh.org.au.

Data analysis

Data analysis mainly involved the use of descriptivestatistics. To determine the difference betweenthose with and without a diagnosis of ASD in termsof demographic variables, chi-square analysis wasused for categorical variables and analysis of vari-ance was used for continuous variables. Alpha wasset at 0.05 for all comparisons.

RESULTS

There were 523 clients registered with OYH on theaudit date, with information on ASD status beingavailable for 476 patients (see Table 1 for demo-graphic and diagnostic characteristics). Data on 47cases were missing because of clinician unavailabil-ity for interview at the time of this study. Of theincluded patients, 3.4% (n = 16) had a confirmeddiagnosis of ASD and 7.8% (n = 37) were reported bytreating clinicians to have suspected ASD traits;3.4% (n = 10) of those with psychotic disorders, and4.1% (n = 5) of those with mood and anxiety disor-ders had a confirmed diagnosis of ASD. SuspectedASD trait rate was highest in the early psychosis

FIGURE 1. Diagnostic overlap in autism spectrum disorder (ASD)co-morbidity.

Autistic traits in a youth mental health service

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clinic (9.6%, n = 28). There were no statistically sig-nificant differences in prevalence rates amongclinics. ASD status was unrelated to gender (c2

(2) = 2.91, P = 0.233). There was a significant differ-ence between the three categories (confirmed ASD,suspected ASD traits and no ASD) with respect toage, (F(2,473) = 7.78, P < 0.001), with post hoc analy-ses (using Games–Howell test) revealing that thosewith a confirmed diagnosis of ASD were signifi-cantly younger, on average, than those with eithersuspected ASD traits (P = 0.002) or no ASD(P < 0.001).

Reporting of autistic traits and possible ASDs wasevenly spread across the clinics, except for the HYPEclinic where there were none reported.

DISCUSSION

The major finding of this study was the increasedrate of those with confirmed prior diagnosis of ASD(3.4%) in a youth clinic sample when compared withcommunity settings (1%).2 Indeed, it might beexpected that the rate of ASD in a psychiatric settingwould be higher than that in the community aspeople with ASD are known to have increased ratesof mental health problems.10 There was no differ-ence in gender with respect to ASD diagnosis, whichis perhaps unexpected given that the reported male-to-female ratio is 4:1 in the general community.11

Interestingly, those with a prior diagnosis of ASDwere significantly younger in the clinic sample. It ispossible that this group may be more vulnerable toearly-onset mental illness and, hence, moreimpaired at an earlier age, with correspondinglymore complex needs. This would need furtherinvestigation.

It is generally accepted that people more pro-foundly affected by ASDs tend to be diagnosed at anearlier age;12 however, those with higher function-

ing, or Asperger-type presentations, may not beidentified until later on when they present to ser-vices with psychiatric disorder. This is consistentwith Mouridsen et al.’s follow-up study of 89 chil-dren with PDD NOS in which 70% developed aco-morbid psychiatric disorder in adulthood, themost common being schizophrenia, compared with11% of controls.13

The results suggest that following specific educa-tion and an increased awareness of ASD, the clinicalstaff were able to identify significant numbers ofyoung people with autistic traits who may have anASD but had not been formally assessed (7.8%).

Limitations

The results from this study may represent an over-estimate of ASD prevalence. Although those withestablished ASD were not assessed by our researchteam because diagnoses were made by specialistsand recorded in reports or clinic letters, they arelikely to be robust. The data were collected via treat-ing clinicians and not from individual client assess-ment. As this was an audit of a whole service, it wasfelt acceptable to interview treating clinicians ratherthan the individual patients or their carers. Such amethodology was successfully used in previousstudies.8,9 It was not mandatory for treating clini-cians to attend the professional development ses-sions. Although not formally recorded, attendancewas felt to be satisfactory across the service. Theinterrater reliability of the data collection tool wasnot measured. The interview tool was a simplethree-item response with written DSM-IV-derivedprompts. Influence from the rater was minimal andtherefore not likely to be subject to substantialrater bias. Data were not collected regardingprevalence of intellectual disability (ID). AlthoughASDs are strongly associated with ID,14 Orygenis not resourced to provide a service for young

TABLE 1. Demographic and diagnostic characteristics of those with confirmed ASD, Suspected ASD traits and no ASD

Confirmed ASD Suspected ASD traits No ASD

Gender male, % (n) 68.8 (11) 51.4 (19) 47.5 (201)Age (years), M (SD)† 17.0 (2.0) 19.8 (3.4) 20.0 (3.0)Diagnostic category‡

Psychosis, % (n) 3.4 (10) 9.6 (28) 87.0 (254)Ultra-high risk for psychosis, % (n) 1.7 (1) 10.3 (6) 87.9 (51)Mood and anxiety, % (n) 4.1 (5) 2.5 (3) 93.4 (114)Borderline personality disorder, % (n) 0 0 100.0 (4)

†Age range 15–25 years.‡Percentage of cases within diagnostic group who have a confirmed ASD, suspected ASD traits and no ASD.ASD, autism spectrum disorder; SD, standard deviation.

R. Fraser et al.

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people with moderate or severe ID. It would,however, be interesting in the future to explorepossible associations between ASD, IQ and age ofonset of psychiatric disorder.

CONCLUSIONS

The rate of confirmed ASDs in a youth mental healthservice is higher than that in community settings.There are a number of other young people withautistic traits and possible undiagnosed ASD. Thepresence of an ASD together with a mental illnesscomplicates not only diagnosis but also the man-agement of both disorders. There already exists anevidence base to support treatment of autism-specific behaviours.15,16 There are, however, limitedguidelines and few empirical studies regarding thetreatment of co-morbidity in ASD, particularly psy-chosis. This study highlights the need to developsuch guidelines, as although relatively uncommonin community settings, the co-occurrence of ASDand psychiatric illness, especially psychosis, is suf-ficiently common in specialist settings, such asOYH, to warrant specific attention.

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